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Community Resource Request Form

Please complete all feilds and once submitted, QX will follow up with next steps and/or a decision within 3 weeks. Note: If you are not a part of the business you are submitting for, the request will be rejected.

Company name

Business Description*

Provide a brief description of your business & the individuals that would be providing that particular service.

Contact Email*

Phone

Address

Business hours

How to Access Services*

What kind of groups do you have experience working with?*

What language(s) are you services available in?*

Service fees/is insurance accepted?*

Accessibility accommodations*

Other relevant information

Business logo*

I am a part of the business I am submitting this request for (required)*

Yes

No

Business website

Queer Intersections (QX)

171 Queens Ave., Unit 420

London, ON

N6A 5J7

info@qxcanada.org

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